A nurse is caring for an infant who has returned to the pediatric unit following surgical repair of a cleft lip. Which of the following actions should the nurse take?

Findings that require immediate follow-up:

• Generalized muscle weakness noted in bilateral lower extremities: This could indicate a neurological or muscular issue, such as Guillain-Barré Syndrome (GBS), which is a concern after a viral infection or vaccination. This requires further investigation and close monitoring for any signs of progression, such as worsening weakness or respiratory involvement.
• Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10: This pain could be indicative of muscle cramping or weakness, which may be associated with GBS or another neurological condition. Pain in combination with muscle weakness should be followed up closely.
• Abdomen slightly firm, bowel sounds hypoactive, and reports last bowel movement was 3 days ago: This could suggest constipation or a gastrointestinal issue. However, the gastrointestinal symptoms may be secondary to the muscle weakness (if part of a systemic condition like GBS), and should be monitored, but it’s not as urgent as the neurological findings.

Findings that do not require immediate follow-up:

• Patellar deep tendon reflexes 1+ bilaterally: A 1+ reflex is on the lower end of normal and does not indicate a severe problem by itself.
• Child is awake and alert, responds appropriately to questions: This is a reassuring sign and does not require immediate follow-up.

A. Applying heat to the affected areas: In vaso-occlusive crises associated with sickle cell disease,heat packs can be a helpful part of pain management, but they should be used with caution and not in all situations.
B. Administering prophylactic antibiotics: While prophylactic antibiotics are important in preventing infections in sickle cell anemia, this is not the immediate priority during a vaso-occlusive crisis.
C. Administering the pneumococcal vaccine: While vaccination is important, it is not a priority during a vaso-occlusive crisis.
D. Promoting bed rest: The nurse should assist the child to assume a comfortable position so that the child keeps the extremities extended to promote venous return; elevate the head of the bed no more than 30 degrees and avoid putting strain on painful joints.